Acute ischemia detection based on parameter value range analysis

ABSTRACT

A heart monitor is disclosed. The monitor computes ST segment deviations and stores the results in heart rate based histograms. Periodically, the monitor analyzes the histogram data to determine a normal range of ST deviation for a particular heart rate range. The monitor computes heart rate dependent ischemia detection thresholds based on the upper and lower boundaries of the normal range.

REFERENCE TO RELATED APPLICATIONS

This application is being filed as a Continuation application of Ser.No. 12/868,308, filed 25 Aug. 2010, currently pending.

GOVERNMENT FUNDING

This invention was made with support under grant 1R43HL096158-01 awardedby the National Heart, Lung and Blood Institute of the NationalInstitutes of Health. The United States government has certain rights inthe invention.

FIELD OF USE

This invention is in the field of medical device systems that monitor apatient's cardiovascular condition.

BACKGROUND OF THE INVENTION

Heart disease is the leading cause of death in the United States. Aheart attack, also known as an acute myocardial infarction (AMI),typically results from a blood clot or “thrombus” that obstructs bloodflow in one or more coronary arteries. AMI is a common andlife-threatening complication of coronary artery disease. Coronaryischemia is caused by an insufficiency of oxygen to the heart muscle.Ischemia is typically provoked by physical activity or other causes ofincreased heart rate when one or more of the coronary arteries isnarrowed by atherosclerosis. AMI, which is typically the result of acompletely blocked coronary artery, is the most extreme form ofischemia. Patients will often (but not always) become aware of chestdiscomfort, known as “angina”, when the heart muscle is experiencingischemia. Those with coronary atherosclerosis are at higher risk for AMIif the plaque becomes further obstructed by thrombus.

Detection of AMI often involves analyzing changes in a person's STsegment voltage. A common scheme for computing changes in the ST segmentinvolves determining a quantity known as ST deviation for each beat. STdeviation is the value of the electrocardiogram at a point or pointsduring the ST segment relative to the value of the electrocardiogram atsome point or points during the PQ segment. Whether or not a particularST deviation is indicative of AMI depends on a comparison of that STdeviation with a threshold.

The threshold may be absolute (e.g. 0.2 mV) or relative to a person'sown ST deviation statistics, as disclosed in U.S. patent applicationSer. No. 10/642,345, invented by Fischell et. al., owned by the assigneehereof, filed August 2003, and U.S. patent application Ser. No.12/461,442, invented by Hopenfeld, filed August 2009, owned by theassignee hereof. Despite this work, there is still a need for aneffective system for setting patient specific thresholds for thedetection of cardiac events.

SUMMARY OF THE INVENTION

An embodiment of the present invention comprises a heart monitor thatmay be chronically implanted or external. The device, which includes ananalog to digital convertor and a processor that performs beatdetection, monitors the time course of a heart signal parameter, namelyST segment deviation, computed from an electrocardiogram. An STdeviation time series is generated by a recursive filter that ispreferably an exponential average filter whose output is a weighted sumof the then existing ST time series value and current ST deviationvalues of analyzable beats. A heart rate value is analogously computedfor each ST deviation value in the time series.

Information pertaining to the ST deviations is stored in histogramformat according to heart rate so as to preserve characteristics of thestatistical distribution of ST deviation as a function of heart rate.Periodically, the monitor analyzes the histogram data to determine anormal range of ST deviation for a particular heart rate range. Themonitor computes heart rate dependent ischemia detection thresholdsbased on the upper and lower boundaries of the normal range. In someinstances, the thresholds are set at specified distances from theboundaries, where the distances are functions of the dispersion of theST deviation data for a particular heart rate range.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates a system for the detection of a cardiac event and forwarning the patient that a medically relevant cardiac event isoccurring.

FIG. 2 is a block diagram of an implanted cardiac diagnostic systemaccording to the present invention.

FIG. 3 is a high level flow chart of a method for detecting ischemia.

FIGS. 4 a and 4 b are a flow chart of a method for classification of adata segment according to its high frequency noise content and signallevel.

FIG. 5 is a flow chart of a routine that processeselectrocardiogram/electrocardiogram segments to perform morphologychecking on QRS complexes.

FIGS. 6 a and 6 b are a flow chart of the preferred embodiment fordetermining the location of PQ and ST points.

FIG. 7 is a flowchart that shows steps for determining a measure ofsegment based ST deviation.

FIG. 8 is a flow chart of a routine that analyzes a segment's STdeviation values and other segment characteristics to determine whetherthe segment's average ST deviation should contribute to long termFiltered measures of ST deviation, ischemia diction, and long term ST/RRhistograms.

FIG. 9 is a routine that computes long term Filtered measure of STdeviation according to an exponential average filter.

FIG. 10 is a routine that maintains a counter that tracks the relativefrequency of abnormal beats based on characteristics other than STdeviation.

FIG. 11 is a flowchart that shows steps for correcting ST deviationaccording to QRS amplitude.

FIG. 12 is a flowchart of a routine that calculates parameters for QRSamplitude correction.

FIGS. 13 a and 13 b are a flowchart of a method for determining STdeviation ischemia detection intervals according to RR interval.

FIG. 14 is a flowchart of an alternative method for determining STdeviation ischemia detection intervals according to RR interval.

FIG. 15 is a table describing ischemia detection thresholds based on thecombination of ST segment information from two leads.

DETAILED DESCRIPTION OF THE INVENTION

Architecture

FIG. 1 illustrates an example of a medical system 12 including implantedcomponents 14 and external equipment 16. An implantable medical device(IMD) 3 includes sensors to monitor a cardiac condition associated witha patient. In one embodiment, sensors include electrodes 4 and 5incorporated into insulated electrical wire leads 2 and 1, respectively,that are preferably placed subcutaneously. The leads 2 and 1 areelectrically connected to the IMD 3, which comprises a case 10 thatserves as a reference potential. Thus, the IMD 3 can obtain threebipolar voltage signals: between the electrode 4 and the case 10,between the electrode 5 and the case 10, and between electrodes 4 and 5.

FIG. 1 also shows external equipment 16, designed to communicate withthe IMD 3, that includes: 1. a physician's programmer 18; 2. an externalalarm system (EXD) 20 which may be implemented as one or more of: apager-type device, a cell phone or PDA type device or a desktop unit;and, 3. a remote monitoring center 22. The physician's programmer 18 has2-way wireless communication 26 for communication between the programmer18, the IMD 3 and the EXD 20. The EXD 20 includes a communication module36 having one or more antenna for wireless communication with the IMD 3,physician's programmer 18 and remote monitoring center 22. Thephysician's programmer 18 provides users with the capability ofinteracting with the IMD 3. The EXD 20 also provides external alarmsignals for alerting a patient and allows two way wired or wirelesscommunications with the remote monitoring center 22. The remotemonitoring center 22 can be one or more third parties including amonitoring service, the patient's doctor, or other intended target.

The programmer 18 shown in FIG. 1 can be used to communicate with theIMD 3 in order to adjust operational parameters and to retrieve datafrom the IMD 3. Communication can include wireless signals 56 sent fromthe programmer 18 communications module 26 to the IMD 3 and incomingwireless signals 54 sent from the IMD 3 to the communications module 26of the programmer 18.

In FIG. 1, the EXD 20 has a patient input module 32 which contains aseries of physical controls such a buttons. A “patient initiate” buttoncan allow for the initiation of communication between the EXD 20 and theIMD 3. An “alarm disable” button can be used to cause an alarm of theIMD 3 and/or EXD 20 to halt rather than repetitively and needlesslyre-alerting a patient. A “panic” button can allow a patient to send analarm with or without attached data from the IMD 3 to a remotemonitoring center 22, even in the absence of IMD 3 or EXD 20 alarmnotification. An “event” button can allow patients to tag events andthereby cause data to be tagged and/or sent remotely. An alarm module 34can operate the communication module 36, sound module 38, visual module40, and vibration module 42, to create an alarm signal 51 that comprisesat least one of: communicating with a 3^(rd) party, a sonic alarm, avisual alarm, and a vibration alarm, respectively.

The communication module 36, with the one or more antennae, providesnear-field and far-field wireless communication. The near-fieldcommunication may use inductively coupled wake-up type communicationmethods such as are well known, while medium and far-field communicationmay rely upon other means. The communication module 36 can employstandardized wireless methods such as Bluetooth, WiFi, the FCC medicalband, and/or cellular communications system such as GSM, CDMA, TDMA. Thecommunication module 36 allows for data and/or voice transmission to andfrom the medical monitoring center 22 via a communication link 44, andalso allows communication with the IMD 3 and programmer 18. The soundmodule 38 has both sound input and output such as a microphone, andspeaker, respectively and associated electronics for providing two-wayvoice communication with the remote monitoring center 22. Examples ofexternal auditory alarm signals 51 include a periodic buzzing, asequence of tones and/or speech which may be a pre-recorded message thatinstructs the patient as to what is happening and what actions should betaken or which may be real speech communicated by the remote monitoringcenter 22. The visual module 40 can include one or more colored diodeswhich are activated continuously, periodically, or according to apattern that is associated with a particular alarm type. The visualmodule 40 may also include a display screen for displaying waveforms,pictures, and text related to system parameters, alarm information, orother information. The vibration module 42 can contain a vibration motorto produce the vibration alarm signal component of the alarm signal 51,and can also contain an accelerometer which can be used to test thevibration alarm and also to measure a patient's physical activity levelwhen the EXD 20 is worn by the patient.

A processing module 50 of the EXD 20 contains a real time clock or timerand other components included within portable smart-devices and pagers.Further, in a preferred embodiment, the EXD 20 is realized using asmart-phone (e.g., an iPhone, Blackberry or Palm), which may, ifnecessary, be implemented using specialized software and/or smartcardsincluding means for wireless communication with the IMD 3. The alarmmodule 34, as well as the other modules of the EXD 20, may beimplemented in hardware or software, and contains all of the necessarycomponents to implement alarming of the patient and/or remote station.The alarm module 34 collaborates with the processor module 50 to providealerting by providing instructions to the processor or by receivingcommands from the processor which cause it to implement alerting asdefined in the alarm protocols, or both.

If an alarm notification is sent from the IMD 3 to the EXD 20, then thealarm module 34 can alert the patient, alert a 3^(rd) party, or no alarmmay be provided and the EXD 20 is simply operated to send data to a 3rdparty for evaluation or storage. When the detection of a lifethreatening event (e.g., AMI or arrhythmia) is the cause of the alarm,the EXD 20 could automatically notify remote monitoring center 22 that aserious event has occurred.

If communication with remote monitoring center 22 occurs, then themessage sent over the link 44 may include at least one of the followingtypes of information as previously stored in the memory provided withinthe EXD's processor module 50 or as directly uploaded from the IMD 3:(1) What type of medical event has occurred, (2) the patient's name,address and a brief medical history, (3) data provided by a GPS module48, the data including GPS coordinates and/or directions to thepatient's location; (4) patient data, historical monitoring data, andthe data that caused the alarm and (5) continuous real time data as itis collected after the alarm. The EXD 20 may be charged with a charger52 to charge a rechargeable power supply 46 in the EXD 20.

FIG. 2 is a block diagram of the IMD 3 with primary battery 72 and asecondary battery 74. The secondary battery 74 is typically arechargeable battery of smaller capacity but higher current or voltageoutput than the primary battery 72 and is used for short term highoutput components of the IMD 3 like the RF chipset in a telemetrysub-system 49 or a vibrator 75 attached to an alarm sub-system 98.According to a dual battery configuration, the primary battery 72 willcharge the secondary battery 74 through a charging circuit 73. Theprimary battery 72 is typically a larger capacity battery than thesecondary battery 74. The primary battery 72 also typically has a lowerself discharge rate as a percentage of its capacity than the secondarybattery 74. It is also envisioned that the secondary battery could becharged from an external induction coil by the patient or by the doctorduring a periodic check-up.

A bipolar signal (e.g. reflecting the potential difference betweenelectrodes 4 and 5 shown in FIG. 1) is fed over wires 17 and 19 to anamplifier/analog filter 86. The amplifier/analog filter 86 amplifies thebipolar signal and filters the signal with a bandpass between 0.25 Hzand 50 Hz, resulting in a conditioned analog signal 87. The conditionedsignal 87 is then converted to a digital signal 88 by ananalog-to-digital converter 91, which preferably samples at a rate of200 Hz. The digital signal 88 is buffered in a First-In-First-Out (FIFO)memory 92 and is digitally filtered with a filter whose transferfunction is the inverse of the high pass transfer function of theamplifier/analog filter 86. Further details regarding this type ofinverse digital filtering are found in EEG Handbook (revised series,Vol. 3), 1988, Chapter 2, Section 2.3.5.7.

For ease of description, only one bipolar signal is shown in FIG. 2. Inthe preferred embodiment, two bipolar signals are processed, and a thirdbipolar signal is derived by subtracting the digitized versions of thetwo bipolar signals. Furthermore, the two bipolar signals are preferablyacquired simultaneously, so that fiducial points (e.g. an ST point, aswill be described with reference to FIGS. 6 a and 6 b determined for onesignal, preferably the signal corresponding to the voltage betweenelectrodes 4 and 5, may be applied to the other bipolar signals (i.e.,the electrode 4 referenced to the case 10 and the electrode 5 referencedto the case 10.)

A central processing unit (CPU) 94 is coupled to the FIFO memory 92. TheCPU 94 is further coupled to a Random Access Memory (RAM) 97 and aprogram memory 95 that stores instructions that implement the methodsdescribed with reference to FIGS. 3-13. The CPU 94 performs the digitalfiltering described above.

A level detector/accelerometer 101 is coupled to the analog to digitalconverter 91. The level detector 101 detects whether a patient's torsois upright or supine and also, if the torso is supine, the extent of itsrotation with respect to the earth (e.g. patient is lying flat onhis/her back, lying on his/her right side or left side.) Many MEMS basedlevel detectors can also operationally serve as inclinometers,accelerometers, and general detectors for motion/force exist.

Additional sensors may communicate with the IMD 3 wirelessly through thetelemetry sub-system 49. The data from these leads may correspond todigitized electrocardiogram signals (that have been processed by aremote subcutaneous device).

The operation of most of the components in FIG. 2 is further describedin U.S. patent application publication number 2004/0215092.

In a preferred embodiment of the present invention, the RAM 97 includesspecific memory locations for 4 sets of electrocardiogram segmentstorage, including recent electrocardiogram storage, working memory forperforming programming operations, memory for storing programmingparameters that may be updated, and patient specific information (e.g.patient name, date of birth).

The telemetry sub-system 49 with an antenna 35 provides the IMD 3 themeans for two-way wireless communication to and from the externalequipment 16 of FIG. 1. Existing radiofrequency transceiver chip setssuch as the Ash transceiver hybrids produced by RF Microdevices, Inc.can readily provide such two-way wireless communication over a range ofup to 10 meters from the patient. It is also envisioned that short rangetelemetry such as that typically used in pacemakers and defibrillatorscould also be applied to the IMD 3. It is also envisioned that standardwireless protocols such as Bluetooth and 802.11a or 802.11b might beused to allow communication with a wider group of peripheral devices.

Flowcharts

FIG. 3 is a high level flow chart of a method for detecting cardiacischemia. The method involves processing 10 second long data segmentscollected by the IMD 3 once every ninety seconds in normal conditions.The segment acquisition rate is preferably increased to once everythirty seconds under various circumstances when there is an abruptchange in RR interval between successive segments (see block 332 of FIG.10, when there is a large jump in the segment average ST deviation(block 310 of FIG. 9), or when the ST deviation exponential averagebecomes close to a threshold (THP or THN in FIG. 13 b or the thresholdsn the table shown in FIG. 14).

In summary, the method comprises the steps of extracting ST segmentinformation from beats within segments and generating a filtered ST timeseries therefrom. This filtered time series is labeled as “CurrentFiltered ST Deviation” in FIG. 3 and will also be referred to as“mStDevN_xavg” below. Current Filtered ST Deviation is then compared toa statistically generated, heart rate dependent ischemia detectionthreshold. If the Current Filtered ST Deviation persistently exceeds thethreshold, then ischemia is detected.

Step 100 involves acquisition of a 10 second data segment, filtering,amplification, and analog-to-digital conversion by the IMD 3. The resultis a digitized data segment comprising 2000 samples. In step 102, thehigh frequency noise content of the segment is assessed. In addition, ifa segment has too many samples that saturate the voltage bandwidth, step102 classifies the segment as noisy. Beat detection in block 104 isperformed only on segments that step 102 has not rejected as too noisy.The RR interval between successive beats in the segment is determined inblock 116, and beats associated with an abnormally short RR interval(e.g. premature ventricular contractions) are excluded from ST deviationcalculations.

The next step 108 involves examining the QRS morphology of remainingbeats by applying tests to various QRS parameters, for example the timebetween the maximum positive and maximum negative slopes. In block 110,the ST deviation for each normal beat is then computed according to thevoltage difference between automatically determined ST and PQ points.

In block 112, the raw ST deviation for each beat is corrected for QRSamplitude based on a non-linear function of the average QRS amplitude ofsinus beats in the segment. The correction is based, in part, on thestatistical distribution of ST deviation as a function of QRS amplitudeover a preceding time period. This feedback of ST deviation statisticsis indicated by the dashed line from block 124 (discussed below) toblock 112.

In block 114, the raw ST deviations are analyzed to determine whetherthe segment was contaminated by noise (such as motion artifact) within afrequency band high enough to disperse ST deviation measurements withina single segment (but low enough to avoid detection by the highfrequency noise detection performed in block 102). Block 114 alsoinvolves additional noise analysis, as will be described below.

Step 122 involves the computation of the average QRS amplitude correctedST deviation of acceptable beats within the current segment. Unless thesegment meets certain exclusion criteria, this segment average updatesan exponential average of ST deviation to generate Current Filtered STDeviation. In step 120, the Current Filtered ST Deviation is added,again subject to certain exclusion criteria, to one of a set of STdeviation histograms where each member of the set corresponds to a rangeof RR intervals. ST(RR0) corresponds to the ST/RR histogram associatedwith the RR interval range RR0. More generally, ST(RRx) corresponds tothe ST/RR histogram associated with the RR interval range RRx. Theparticular ST/RR histogram (ST(RRx)) that is updated depends on the RRinterval which encompasses the exponential average of RR intervaldetermined in block 118. QRS amplitude histograms will analogously bereferenced as ST(QRx), where QRx is a range of QRS amplitudes.

In block 126, the Current Filtered ST Deviation is compared to an RRdependent ischemia detection threshold periodically determined by block124. If the Current Filtered ST Deviation is persistently above or belowupper or lower ST deviation thresholds, respectively, acute ischemia isdetected.

Block 124 also periodically performs an analysis of the relationshipbetween QRS amplitude (QR) and ST deviation. This analysis is based ondata in a set of ST deviation histograms, where each member in the setcorresponds to a range of QRS amplitudes, updated in block 120. Theresult of this analysis is QR dependent correction factors thatparameterize QR correction performed in block 112.

FIGS. 4 a and 4 b are a flow chart of step 102 (FIG. 3) forclassification of a data segment according to its high frequency noisecontent and signal level. Block 140 is the initiation of a loop. In thisFigure and in other Figures in this Specification, loops are shown as aninitial block with the steps in the loop shown in a dashed line. In FIG.4 a, the steps within the loop are steps 142 to 160. In step 140, theloop is set to repeat so that a number of non-overlapping subsegmentsare separately assessed for noise. In the preferred embodiment, where a10 second long segment consists of 2000 samples, the segment is dividedinto 3 subsegments. According to block 140, the loop is repeated foreach of the subsegments or until a signal level saturation threshold isreached (block 156), whichever occurs first.

In block 142, a noise figure of merit (FOMs) variable for subsegment iis initialized to 0. A variable dSlast, which tracks the sign of signalchanges, is initialized to 0. In block 144, a loop through each samplein subsegment i is initialized. In block 146, the number of consecutivesaturated samples, which may be counted by a simple counter, is comparedto a threshold THcsat, which is set to 6. If the number of consecutivesaturated samples exceeds THcsat, control is transferred to block 154,in which a saturation counter (satcnt) is incremented. Block 154 thentransfers control to block 156, which checks whether satcnt is greaterthan a threshold THsat, set to 100. If so, the segment is classified asnoisy in block 168 (FIG. 4 b). Otherwise, control transfers from block156 to 148, where processing also continues if the condition in block146 is not satisfied.

In block 148, the first difference of the signal S at the current sample(j) is computed. In block 150, the sign of dS (positive or negative) iscompared to dSlast. If the signs are the same, control transfers toblock 152, which increases FOMs(i) by the absolute value of dS. If thesigns of dS and dSlast are different, control transfers to block 158,which increments FOMs(i) by a multiple (a) of dS. In this manner,changes in signal polarity increase the assessed noise level of thesignal more than deflections of the signal in the same direction.Weighting FOMs(i) according to signal amplitude (dS) allows a segment tobe considered not noisy if it contains high frequency, low amplitudesignal fluctuations. In an alternative embodiment, FOMs(i) is weightedby dS normalized to a measure of the maximum voltage difference withinthe segment (i.e., max(S(k))−min(S(k)) over all k within the segment).

From either block 152 or block 158, control transfers to block 160,which sets dSlast to dS.

Once all subsegments have been processed (if the loops have not beenbroken based on the outcome of block 156), control transfers to block162 in FIG. 4 b. Block 162 sets the FOM for the segment as the maximumof the FOMs of the subsegments. In this and other Figures in thisSpecification, Matlab vector notation will be used to represent arrayssuch as FOMs=[FOMs(1) FOMs(2) FOMs(3)]=FOMs([1:3]).

Next, block 164 checks whether the segment FOM exceeds a threshold,THnoise. If not, in block 166, THnoise is set equal to a constantCleanTH. If the FOM of the segment exceeds THnoise, the segment istagged as noisy in block 168, and THnoise is set equal to a threshold,NoiseTH, that is lower than CleanTH. In this manner, the noise thresholdis characterized by hysteresis, whereby a segment is more likely to beclassified as noisy if it follows a noisy segment.

FIG. 5 is a flow chart of a routine that performs morphology checking onQRS complexes. QRS complexes are classified as normal or abnormal. STdeviation is not computed for abnormal beats. Blocks 200 through 207 areperformed iteratively for each beat in a segment of electrocardiogramdata. The steps shown in FIG. 5 are performed after QRS complexes havebeen detected in block 104 (FIG. 3), preferably by a routine based onthe slope based scheme described in U.S. patent application Ser. No.12/232,281, entitled “Methods and Apparatus for Detecting Cardiac EventsBased on Heart Rate Sensitive Parameters”, filed September 2008, ownedby the assignee of the present invention. For each beat, the absoluteminimum of the QRS (Rpeak) is located and the location of the precedingpositive peak (initpk), if any, is determined. The average RR intervalfor the segment is computed. Based on the average RR interval, PVC beatsare located, tagged, and not included in the segment's ST deviation. STdeviation is not determined for PVC beats.

For each non-PVC beat in the segment, the minimum QRS slope (minQRS) islocated. For those beats that have a dominant negative QRS complex,block 202 searches for a positive peak in the slope (maxQRS) within asearch window located after Rpeak. In particular, the search windowbegins at 2 samples after Rpeak and ends 12 samples after Rpeak. In thefigures, a search window is denoted by W[a,b], where a is the windowstarting point (sample index integer) and b is the window ending point.The sample index (location) associated with a particular reference pointis denoted by appending “_ind” to the particular reference point. Forexample, the index associated with Rpeak is Rpeak_ind.

If a local peak in the positive slope is found at either end of thepurposely too wide search window designated in block 202, block 205 tagsthe beat as abnormal and increments the “bad beat counter” labeled asmQMorphcnt and in block 207 the routine searches for the next beat orthe end of the segment. Otherwise, if block 202 has found a localpositive slope peak, control transfers to block 203, which checkswhether there is an appropriate decrease in the positive slope aftermaxQRS. In particular, within W[maxQRS_ind+1, maxQRS_ind+8], the routinesearches for the first point where the slope is less than ⅜ of maxQRS.If no such sample can be found, the beat is tagged as irregular, andmQRMorphcnt is incremented in block 205, and processing continues inblock 207. Otherwise, control passes from block 203 directly to block207, which repeats the above process for each QRS detected in thesegment.

FIGS. 6 a and 6 b are collectively a flowchart that shows the preferredmethod for computing ST points. An analogous method may also beimplemented to locate PQ points. In block 220 of FIG. 6 a, the ST searchwindow is set between maxQRS_ind+2 samples and maxQRS_ind+12 samples. Inblock 222, the slope of the slope (“second finite difference”) of thesignal is computed by twice applying the slope operator:X(i+3)+2*X(i+2)+X(i+1)−X(i−1)−2*X(i−2)−X(i−3), where X(i) is the valueof the waveform S at sample i for the first slope operation and then isthe value of the slope at sample i for the second operation. The searchstops at the first sample at which the second finite difference is lessthan a specified multiple (ST_coef) of QR_xavg, an exponential averageof peak to peak QRS amplitude (QR). In the preferred embodiment, ST_coefis 1.

If such a qualifying sample is found (at sample j), block 224 transferscontrol to block 226, which sets a new search window starting at thesample after j (sample j+1) and again ending at maxQRS_ind+12. In block228, this window is searched for two consecutive samples at which theabsolute value of the second finite difference is less thanST_coef*QR_xavg.

If two such consecutive samples are found, with the latter of the twolabeled as “k”, control is transferred from block 230 to block 234 (FIG.6 b), which sets the ST point (ST_ind) based on the value of k, subjectto constraints on the location of the ST point. In particular, the STpoint must be at least 2 samples after the Spt (defined in block 203 ofFIG. 5), and within a 3 sample window centered on Rpeak_ind+ST_int,where ST_int is an adaptive parameter that governs the location of theST point.

Specifically, if k is within this three sample window, then the ST point(ST_ind) is chosen as the sample k. Otherwise, if k is before thiswindow (i.e. closer to Spt than the beginning of this window), thenST_ind is set at the earliest sample in this window, Rpeak_ind+STint−1,subject to the previously mentioned constraint regarding the location ofST_ind relative to the Spt. If k is after the window, then then ST_indis set at the latest sample in this window, Rpeak_ind+STint+1.

Block 234 then transfers control to block 236, which updates theadaptive parameter ST_int according to the number of samples betweenST_ind and Rpeak. ST_int is preferably updated according to anexponential average filter. The exponential average of a variable (V) isexpavg(V, Δ, α, min, max, mindelt, maxdelt), which means that thevariable V is updated by the current value A, with an update weighting½^(α), subject to constraints on the maximum and minimum allowable valuefor the variable and changes in that variable. Ignoring the constraints,expavg(V, Δ, α, ( ) ( ) ( ) ( )) is V(j+1)=((2^(α)−1)*V(j)+Δ)/2^(α).

Returning to block 224, if no second finite difference within the STpoint search window was less than the threshold, then control transfersto block 232, which increments mQMorphcnt. Similarly, if no qualifyingsample is found in block 230, control is transferred to block 232.

The routine shown in FIGS. 6 a and 6 b may be modified to locate PQpoints. In this case, the preferred search window (block 220) is(MinQRSInd−4, MinQRSInd−20). ST_coef in block 1004 is −1 while theabsolute value of ST_coef, 1, is used in block 222. The sign of ST_coefwill depend on expected QRS morphology; in the case of a QRS with a V2like morphology (small R, large S), the curvature of the PQ and STsegments have opposing signs. In block 234, the PQ point is not allowedto come within four samples of the R wave peak (i.e., maximum value ofthe initial upstroke of the QRS before the large downstroke.)

FIG. 7 is a flowchart that shows steps for determining a measure ofsegment based ST deviation (mStDevN_xavg), which is an averaged,effectively filtered version of a number of beat based ST deviationmeasurements. Steps 250 through 260 are performed for each(provisionally) analyzable beat that has associated ST and PQ points. Inblock 250, ST deviation (Stdev) is determined by the difference betweenthe signal values of the samples surrounding the ST and PQ points,respectively. In the preferred embodiment, the PQ signal value is equalto the average of the signal over four consecutive samples starting atthe sample that is two samples earlier than the PQ point. In thepreferred embodiment, the ST signal value is equal to the average of thesignal over four consecutive samples starting at the sample that is onesample earlier than the ST point.

Stdev is corrected for QRS amplitude in block 254 according to themethod described in FIG. 11. Control passes to block 256, which checkswhether the difference between both (i) Stdev and the median STdeviation at the resting heart rate (STm(RR0)); and (ii) Stdev and thecurrent long term ST deviation exponential average (mStDevN)_xavg),exceed a threshold maxchg. If so, the beat is tagged as non-analyzablein block 260 and does not figure into the segments average ST deviation.Otherwise, an analyzable ST deviation beat counter is incremented inblock 258. The segment average ST deviation (mStDevNavg) is calculatedin block 262.

Processing continues at block 300, shown in FIG. 8, which is a flowchart of a routine that analyzes a segment's ST deviation values andother segment characteristics to determine whether the segment's averageST deviation (mStDevNavg) should contribute to long term currentfiltered ST deviation (see block 122 of FIG. 3), ischemia diction, andST/RR histograms. Block 300 performs a number of tests to determinewhether the current segment's ST deviation (mStDevNavg) should beconsidered valid for two purposes: (1) ischemia detection; and (2)contributing to the ST/RR histograms. If a segment is too abnormal, orappears to correspond to a rapid change in physiological state (e.g. achange in heart rate), as defined by the tests in block 300 (and block306 described below), its ST deviation can not be relied on for ischemiadetection or for contributing to ST/RR statistics. The three tests are:(1) whether the average RR interval of the current segment is within ¾and .1.5 times the average RR interval of the previous segment; (2)whether mQMorphCnt (see blocks 205 of FIG. 5 and block 232 of FIG. 6 a)is low; and (3) whether the number of PVC's is low (less than 2). Ifeither test 1 or tests 2 and 3 are positive, then the segment's STdeviation may qualify for ischemia detection/statistics, so block 302transfers control to block 304. Otherwise, if both test 1 and tests 2 or3 are negative, block 302 transfers control to block 332 of FIG. 10,which results in the exclusion of the segment's ST deviation fromischemia detection/statistics (by skipping past block 316 of FIG. 9).

Returning to the “yes” branch of block 302, block 304 calculates ameasure of the noisiness (STFOM) of the ST deviations of the beats inthe current segment. If the segment was contaminated by noise such asmotion artifact, the variance of the ST deviations will tend to berelatively large, which in turn implies that the average ST deviationshould not be trusted. To assess ST deviation noise/variance, theroutine described with reference to FIG. 4 a is applied with the STdeviation of each individual (analyzable) beat constituting signal S,and with the signal saturation steps (146, 154 and 156) excluded. Afterthe ST deviations of all the analyzable beats have been processed, theresulting FOM (block 152 of FIG. 4 a) is normalized by the number ofanalyzable beats in the current segment, and the result is the STFOM.

In block 306, STFOM is compared to a threshold. If the threshold isexceeded, control passes to block 332 of FIG. 10, which results in theexclusion of the segment's ST deviation from ischemiadetection/statistics. Otherwise, processing continues in block 310 ofFIG. 9. (In an alternative embodiment, STFOM controls the weighting ofthe ST deviation exponential average updating, with an inverserelationship between the magnitude of STFOM and the amount the currentsegment's ST deviation contributes to the long term exponential averagein block 314 of FIG. 9.)

Block 310 (FIG. 9) checks whether the difference between mStDevNavg andthe current long term, filtered ST time series (mStDevN_xavg) exceeds athreshold. If so, mQMorphCnt is incremented in block 312 and the segmentis not added to the ST/RR histograms. Subject to block 410 of FIG. 11,which describes an additional criterion for excluding mStDevNavg fromcontributing to mStDevN_xavg, control then passes to block 314, which isalso invoked from the “no” branch of block 310. In block 314, theFiltered exponential average (mStDevNavg) is updated according tomStDevNavg. In block 316, if the result of the block 310 test wasnegative, mStDevN_xavg is added to the ST/RR histograms. Detailsregarding ST/RR histograms are described in U.S. Pat. No. 7,512,438,entitled “Implantable System for Monitoring the Condition of the Heart”,owned by the assignee hereof. The exponential average of the RR intervaltime series determines which of the ST(RRx) histograms is incremented.

In an alternative embodiment, block 310 applies additional tests to helpprevent noisy data from being added to ST/RR histograms. One additionaltest is to compare the current mStDevNavg with the most recent priormStDevNavg. If the difference between the two exceeds a threshold, thehistograms are not updated. In yet another alternative embodiment, ameasure of the dispersion of the past few mStDevNavg results is computedand compared to a threshold. If the dispersion is too large, histogramsare not updated. Measures of dispersion include, without limitation,standard deviation and a sum of first order differences (absolutevalues) from the mean.

FIG. 10 is a flow chart of a routine that tracks the relative frequencyof variant beats. Variant beats are broadly defined as beats thatdeviate from an established pattern of normal sinus rhythm beats.Variant beats include beats that resulted in an increment of mQMorphcntduring the QRS processing described with respect to FIG. 5. In addition,mQMorphcnt is also updated in block 232 (FIG. 6 a) and block 312 (FIG.9). The relative frequency of variant beats is stored in a variablemqmorph. If mqmorph is above a threshold for a certain period of time,the system is preferably configured to respond in a user-programmablemanner such as generating an alarm.

The mqmorph variable is updated after each segment is processed. Themanner in which mqmoprh is updated depends on the outcome of the testsapplied in blocks 302 and 306 (FIG. 8). If the outcome of this testsuggests that the current segment is relatively “normal”, mqmorph iscomputed in block 330. In particular, in block 330, mqmorph is increasedby mQMorphCnt²−qmorphleak, subject to the constraints that mqmorph cannot be negative or greater than 6*qmorphleak, where qmrophleak is aparameter. According to the above equation that updates mqmroph,qmorphleak acts like a “drain” that tends to “empty” mqmorph. Thus,mqmorph tends to remain at a low value unless there are a number ofsegments within a relatively short period of time with relatively highmQMorphCnts.

If the segment is considered relatively “abnormal” according to thetests applied in blocks 302 or 306, control passes to block 332. IfmQMorphcnt is greater than 1 or the segment's average RR interval isvery different from the previous segment's RR interval, then mqmorph isincreased in block 336 by mQMorphCnt²+qmorphlimit−qmorphleak, subject tothe same constraints on the maximum and minimum mqmorph values describedwith respect to block 330.

Returning to block 332, if none of tests 1, 2 or 3 is positive, thencontrol passes to block 338, which determines whether the number ofPVC's is low (less than 2). If so, block 340 increases mqmorph in thesame manner as block 330 except that qmorphleak is divided by 2.

FIG. 11 is a flowchart that shows steps for correcting ST deviationaccording to QRS amplitude (QR). In block 400, the segment average QRamplitude (QRav) is computed based on the values of all analyzable beatsin the segment, i.e. those beats whose ST deviations are eligible tocontribute to segment average ST deviation (mStDevNavg). Also, anexponential average of QR amplitude is updated based on QRav as follows:QR exp. avg=expavg(QR exp. avg., QRav, 2, NA, NA, NA, NA).

Block 402 is the beginning of a loop over all of the analyzable beats.In block 404, the ST deviation (STdev(i)) of the analyzable beat i iscorrected by adding a term min(1,(max((abs(del)−disp),0)/(disp))))*corr,where corr=STm(QR0)−STm(QRavb), del=STdev(i)−STm(QRavb),disp=0.5*(max(STm(QRavb))−min(STm(QRavb)). STm(QR0) is the median STdeviation associated with the median QR amplitude. STm(QR0) is computedfrom ST/QR histograms, as will be further described with reference toFIG. 12. Similarly, STm(QRavb) is a quasi-median ST deviation for the QRbin associated with the QR amplitude of the current segment (QRav).(More specifically, QRavb in the expression is the QR bin correspondingto the QR range in which QRav falls.) STm(QRavb) is computed from ST/QRhistograms, as will be further described with reference to FIG. 12, andis further modified in block 406, as will be discussed below.

The correction (con) is not added directly to STdev(i). Instead, theamount of the correction (corr) that is added to STdev(i) depends on howclose STdev(i) is to its expected value, which is STm(QRavb). IfSTdev(i) varies substantially from this expected value, then there isless confidence that the correction corr is appropriate. The quantitydisp controls the amount of con that is added as a function of thedifference (del) between STdev(i) and STm(QRavb).

In step 406, STm(QRavb) is updated to decrease del. For example, if theuncorrected STdev(i) was larger than STm(QRavb), then STm(QRavb) isslightly increased.

Returning to segment based processing, in block 412, the average delover the segment is compared to a threshold. If the average del exceedsthe threshold, the segment ST deviation (mStDevNavg) is excluded fromthe ST/RR histograms in block 414. Block 408 tests whether both QRav andmStDevNavg are positive but sufficiently small that the applicable ST/QRhistogram has few if any entries. If so, then block 410 excludesmStDevNavg from both the ST/RR histograms and the update of the STexponential average (block 314 of FIG. 9). Exclusion is appropriatebecause small positive values of both QRav and mStDevNavg could resultfrom a device related factor such as high lead impedance. To enable thesystem to adapt to new, low values of QRav and mStDevNavg, mStDevNavg(not mStDevN_xavg) is added to the appropriate ST/QR histogram.

FIG. 12 is a flowchart of a routine that calculates parameters for QRSamplitude correction required by the routine described with reference toFIG. 11. In block 450, an array of ST deviation histograms are createdand/or updated, which each histogram corresponding to a range of QRSamplitudes (QR), measured as the difference between the maximum andminimum waveform values of the QRS complex. Techniques for creatingarrays of ST deviation histograms are described in U.S. Pat. No.7,512,438, entitled “Implantable System for Monitoring the Condition ofthe Heart”, owned by the assignee hereof. The ST/QR histograms areupdated with the QR exponential average (block 400, FIG. 11) after everysegment for which the QR exponential average was updated.

In block 452, the median ST deviation (STm(QR0)) for the median QRhistogram is computed. STm refers to median ST deviation, while the x inSTm(QRx) refers to the QR histogram x. QR0 refers to the median QRhistogram. For example, if there are ten ST deviation histograms as afunction of QR amplitude, one histogram each for the QR ranges 1-10,11-20 . . . , 91-100, and the median QR amplitude is 77, then QR0 refersto the ST deviation histogram associated with the QR range 71-80. Inthis example, the histogram associated with the range 61-70 would beQR−1, the histogram associated with the range 81-90 would be QR1, thehistogram associated with the QR range 51-60 would be QR−2 etc.

Block 454 is the beginning of a loop that first processes each ST(QRx)histogram associated with QR<QRm and then processes each ST(QRx)histogram associated with QR>QR0. The current histogram being processedis tracked by index i. In block 456, the current index i is stored. Inblock 458, i is decremented until the number of elements in consecutivehistograms exceeds a threshold, THbin. For example, if i=−1, THbin is200, and the number of elements in STQ(QR−1) is 240, then i is notdecremented at all. As used above, “number of elements” refers to thesum over all bins within a particular histogram. Returning to the aboveexample, if the number of elements in STQ(QR−1) is 150 and the number ofelements in STQ(QR−2) is 70, then i decremented once. The numberoperator n will refer to the number of elements in a histogram or arrayof histograms. Continuing with the above example, N(STQ([−1:−2]))=220.

In block 460, the median ST deviation over the current set of ST(QRx)histograms ST([iold:i] is calculated. In block 462, the quasi-median ST(STQm([iold:i])) for the current set of ST(QRx) histograms is set asmax(min(STQm,UL*STm(iold+1)),LL*STm(iold+1)), where UL and LL areparameters that control the amount by which the current quasi-median isallowed to vary from the median ST of the adjacent QR histogram(STm(iold+1). Preferred values of UL and LL are 1.2 and 0.5,respectively, so that the quasi-median is not allowed to exceed 1.2times the adjacent quasi-median or be less than 0.5 times the adjacentquasi-median. (When proceeding in the direction of larger QR values(block 464), the max and min statements in block 462 are reversed.)

In block 464, the above described process beginning with block 456 isrepeated for ST histograms associated with QR>QR0.

FIGS. 13 a and 13 b are a flowchart of a process for setting STdeviation thresholds for detecting acute ischemic events. In block 480,an array of ST deviation histograms are created and/or updated, whicheach histogram corresponding to a range of RR intervals. Techniques forcreating arrays of ST deviation histograms are described in U.S. Pat.No. 7,512,438, entitled “Implantable System for Monitoring the Conditionof the Heart”, owned by the assignee hereof. An exponential average ofthe average segment RR interval preferably determines which ST(RRx)histogram is accessed. This histogram is updated with mStDevN_xavg, aspreviously described.

The threshold setting process will first be described for positive STdeviation thresholds, i.e. thresholds for detection of ST deviationsthat are greater than normal. An analogous procedure sets negative STdeviation thresholds, i.e. thresholds for detection of ST deviationsthat are less than normal.

In block 482, the positive ST deviation threshold for each RR intervalis determined according to the process to be described with reference toFIG. 13 b. For example, if there are 5 RR ranges, from 301 ms-500 ms,501 ms-700 ms, 701 ms-800 ms, 701 ms-900 ms, and 900 ms-2000 ms, thenthere are 5 ST(RRx) histograms. The notation [RR] means that theseparate RR ranges are to be taken as a vector. Continuing with theabove example, ST([RR])=ST([1:5]). The threshold function (implementedby the routine in FIG. 13 b), is indicated by TH( ). Thus, in the aboveexample, TH([RR]) is an array with 5 thresholds, one corresponding toeach RR array, i.e. [TH(1) TH(2) TH(3) TH(4) TH(5)].

In block 484, the maximum threshold over the threshold array isdetermined. In block 486, the thresholds are set equal tomaxTH+(TH(RRx)−maxTH).*min(1,(maxTH−TH(RRx))/THC), where THC is aconstant that depends on the dynamic range of the ST measurements. If atypical ST range is between 0 and 1000, then a preferred value for THCis 2000. For example, TH(1) is equal tomaxTH+(TH(1)−maxTH).*min(1,(maxTH−TH(1))/THC).

In block 488, the RR arrays with a sufficiently large number of entries,i.e. at least THbinsize elements, are located and identified as“gdbins.” Again, the number operator N refers to the number of elementsin a particular histogram. Similarly, the RR arrays with less thanTHbinsize are located and identified as bdbins. In block 490, for anybdbin that is not between gdbins, the threshold is set as the thresholdof the nearest gdbin+SF, where SF is a safety factor. In block 492, forbdbins inbetween gdbins, the threshold is set as the average of the twonearest surrounding gdbins.

In block 494, steps 482-492 are repeated for negative thresholds. Forthis processing, the max operator in block 484 is replaced with the minoperator, and (maxTH−TH(RRx))/THC in block 486 is replaced with−(minTH−TH(RRx))/THC.

In an alternate embodiment, instead of correcting ST deviation for QR(FIG. 12) and setting RR dependent thresholds (FIGS. 13 a-13 b),thresholds are set directly based on both QR and RR, which comprise atwo dimensional parameter array. For example, if there are 8 QR rangesand 5 RR ranges, separate ST deviation statistics are kept for each of40 bins. Thresholds are set as in FIG. 13 a, with two dimensionalinterpolation/extrapolation in blocks 490 and 492 instead of onedimensional interpolation/extrapolation.

Finally, step 496 increases negative thresholds in the cases where theminimum negative ST deviation boundary (minbin) (described further belowwith respect to FIG. 13 b) over all RR intervals is greater than 0. Inthis case, for reasons similar to those set forth below with regard tostep 512 of FIG. 13 b, the lower threshold (THn(RRx)) for each RRxinterval is changed to a value based on the minimum lower threshold(min(THn(RRx)) plus an adjustment factor THnadj. For example, assumingthat there are only two RRx ranges, and that the minimum ST deviationoccurs in the second range (RR2), the minbin for RR2 is 50, and that thethreshold for RR2 is −200, the negative threshold for RR2 is raised to−150 if THnadj is set to 100. Conversely, if the negative threshold forRR2 (before block 496 is invoked) is −125, then the threshold for RR2remains at −125, since −125>−150. THn(RR1) is also increased to −150 ifit was lower than that value. It will be appreciated that the choice oflead polarity is arbitrary, so that the above adjustments may apply tothe positive thresholds depending on lead orientation and polarity.

FIG. 13 b is a flowchart that shows the steps for computing the positiveand negative detection thresholds for a particular ST(RRx) histogram.This routine is invoked by block 482 of FIG. 13 a. In block 500, theupper ST deviation boundary bin (maxbin) is found by locating the binfor which the sum of all elements in the bin and in bins with larger STdeviations is less than a threshold THbnd. For example, if there are 10ST bins that cover ST deviations in the ranges of 0-9, 10-19 . . . 80-89and >90, respectively, and there are 15 elements in bin 70-79, 5elements in bin 80-89 and 3 elements in bin >90, and THbnd is 10, thenmaxbin is bin 80-89 since there are less than 10 elements collectivelyin bin 80-89 and above but more than ten elements collectively in bin70-79 and above.

THbnd depends on the number of entries in a histogram. THbdn ispreferably set at THbndbase*NH, where THbndbase is the desired STdeviation cutoff per unit time, and NH is amount of time during whichdata has been inserted into the histogram. For example, if THbndbase is10 entries/day, and a histogram has 5 days of entires, then THbnd is 50.

In block 502, the lower ST deviation boundary bin (minbin) is foundanalogously to the procedure described with reference to block 500.

In block 504, the median ST (STm) is found for the histogram ST(RRx). Inblock 506, the positive threshold (THP) is set equal to STm+U*disp_pos,where disp_pos=(ST(maxbin)=STm) and U is a programmable parameter. (TheRRx parenthetical is implied for quantities such as THP, STm and is notshown in blocks 506-514.) Continuing with the above example, wheremaxbin corresponds to ST deviations between 80-89, ST(maxbin) is setequal to 85, the midpoint (in terms of ST deviation) of maxbin. If themedian ST over all bins is 50 and U is 2, then THP is 50+2*(85−50)=120.The threshold THP is thus a function of the dispersion rate of theST(RRx) distribution.

In an alternative embodiment, the threshold is a function of the rate offall off in the tail of a distribution. The rate of fall off may bemeasured by locating the ST deviation boundaries, as described above. Ifthe histogram bins are labeled as [B1, B2 . . . BN], with B1 the lowerboundary bin and BN the higher boundary bin, the difference in thenumber of elements between bins B1 and B2 is n(B2)−n(B1)=d(2,1), whered(a,b) is defined as the difference operator between bins a and b. Twomeasures of the rate of fall off of the lower tail of the distributionare: (1) max(d(i+1,i)) with i taken over the first p histogram bins; and(2) n(1:p)/n(total histogram), so that if the cumulative number ofentries in the first p histograms is relatively large compared to thetotal number of entries in the histogram, the rate of fall toward theboundary is relatively sharper. An analogous rate of fall off iscomputed for the upper boundary.

In another alternative embodiment, if particular lead registers a normalQRS morphology, the positive threshold is never allowed to fall beneatha minimum value that is selected according to population basedstatistics. In yet another alternative embodiment,THP=STm+U*disp_pos*f(disp_pos), where f is a function that mapsrelatively low values of disp_pos to values greater than one, and mapsrelatively high values of disp_pos to values less than or equal to one,in such a manner that the detection thresholds for small and largedispersions are brought somewhat closer together. An inverted sigmoidaltype shape for f is preferred. In this manner, the thresholds associatedwith small dispersions are relatively increased, which may help to avoidfalse positive detections that would otherwise result from very smalldispersions.

Next, block 508 determines whether the ST deviation associated with theminimum bin is greater than a parameter Zeroth, which is a programmableparameter that governs the ST deviation level at which an ST deviationpolarity change is deemed to occur, i.e. Zeroth is the boundary betweenpositive and negative ST deviations. Zeroth will generally be 0, exceptthat for some subjects, it may be desirable to set Zeroth as slightlynegative since some random fluctuations in ST deviation can cause somenegative (but small) ST deviations to accumulate in the ST histograms.Also, device related issues such as filtering could result in an offsetto “true” ST deviations and thus result in a non-zero value for Zeroth.

If the ST level associated with minBin is greater than Zeroth, thenblock 510 provisionally sets the negative threshold analogously to thepositive threshold setting described with reference to block 506.Programmable parameter L1 (block 510) may be set to a different valuethan programmable parameter U (block 506). In block 512, THN is notallowed to be greater than minTHul, a programmable parameter. THN is notallowed to be less than Zeroth less a margin of safety (NSF). Forexample, if Zeroth is 0, and NSF is 10, THN will be set no lower than−10. This floor on THN allows for greater sensitivity to detect changesin polarity. That is, if a negative ST deviation is not normal for aparticular RR interval and lead, then the floor on THN allows a negativeST deviation to be detected with greater sensitivity if the provisionalthreshold set in block 510 is less than Zeroth-NSF.

On the other hand, if the provisional threshold set in block 510 ispositive and “too large”, then specificity may be compromised sincesmall but positive ST deviations may be normal, even if not previouslyoccurring in a particular subject. If the small ST deviations areassociated with small QR amplitudes, then blocks 408 and 410 of FIG. 11will prevent false positive detections. However, if the QR amplitude isnot “small” but the ST deviation is small and positive, detection maystill not be appropriate. The parameter minTHul dictates the level atwhich an ST deviation can not be considered as a true positive,regardless of ST/RR distributions. If a typical ST deviationdistribution ranges between 400 and 1000, then minTHul is preferably setat 50 (relatively close to zero).

Returning to block 508, if ST(minbin) is less than or equal to Zeroth,then the negative threshold is set in block 514 analogously to block506, with L2 being an individually set programmable parameter.

In the preferred embodiment, the parameters U, L1 and L2 (blocks 506,510 and 514) change from relatively large values to lower values overtime after the device 3 (FIG. 1) is first implanted.

In an alternative embodiment, U (block 506), L1 (block 510) and L2(block 514) are heart rate dependent, so that the values of U, L1 and L2increase with increasing heart rate.

FIG. 14 is an alternative embodiment of a process for setting STdeviation thresholds for detecting acute ischemic events. Block 600 isanalogous to block 480 (FIG. 13 a). Block 602 indicates the initiationof a loop through each RR interval range. This loop is indexed by thecounter i. In block 606, the number of elements in the current RRinterval bin (RR(i)) is compared to a threshold TH1bin. If the thresholdis exceeded, control passes to block 608, which sets the threshold ofbin i to the value determined by getbinTH (FIG. 13 b). Next, in block610, the number of elements in RR(i) is compared to another threshold,TH2bin, which greater than TH 1 bin. If TH2bin is exceeded, then theroutine continues processing with the next RR interval, as indicated bythe increment of i in block 612. Otherwise, if N(RR(i)) is less thanTH2bin, then there is relatively less confidence in statisticalestimates associated with RR(i), and the threshold is pushed furtheraway from the median by an amount P, in block 614. Processing thencontinues in block 612.

Returning to block 606, if TH1bin is not exceeded, control passes toblock 681 m, which sets the threshold of the current bin equal to thethreshold of previous bin (i−1). Processing then continues in block 612.

FIG. 15 is a table 700 that shows ischemia detection thresholds based onthe combination of ST segment information from two leads, designated asthe left and leftup leads respectively (leads 2 and 1 of FIG. 1). STdeviations of the leads are combined by effectively normalizing theindividual leads' ST deviations to their corresponding thresholds.(Thresholds are assumed to be RR dependent but this need not be thecase.) Column 702 of the table indicates the relative polarities of theST shifts associated with the two leads. Column 704 shows the classifierthat is generated to compare to a threshold shown in column 706.

The second row 708 in the table applies when the ST deviations of boththe leads are above the pertinent (preferably RR dependent) medianlevels. The ST deviations are effectively normalized by subtracting thepositive boundary ST deviation (STMX, which is label for the quantityST(maxbin) described with reference to blocks 500 and 506 of FIG. 13 b)and dividing the resulting quantity by the difference between thepositive threshold and the positive boundary. For example, for the leftlead, if the positive boundary STMX_left is 10, the positive thresholdTHP_left is 20, and the ST deviation (ST_left) is 14, the effectivenormalized ST deviation is (14−10)/(20−10)=0.4.

Because the thresholds in column 706 are less than 2, ischemia may bedetected when detection would not occur from either lead alone.Continuing with the above example for the left lead but adding in theleftup lead, if the positive boundary STMX_leftup is 14, the positivethreshold THP_leftup is 30, and the ST deviation (ST_leftup) is 29, theeffective normalized ST deviation for the leftup lead is(29−14)/(30−14)=0.9 (with integer based arithmetic). When the 0.9 forthe leftup is added to the 0.4 of the left, the result is 1.3, thethreshold for detection.

Combinations of ST deviations above and below the medians are shown inthe remaining rows in the table 700.

In the preferred embodiment, it is desirable to base ischemia detectionboth on the relative “distance” classifiers described above but also onabsolute “distance” from the boundary thresholds, as described in U.S.patent application Ser. No. 12/461,442, invented by Hopenfeld, filedAugust 2009. (The “absolute” distance may be either based in units ofabsolute voltage or be based on a fraction of QRS amplitude.) Ischemiais detected when any of the absolute or relative classifiers is aboveits corresponding threshold for a certain number of consecutivesegments.

As is well known, integer based arithmetic, which is the preferredsystem for carrying out the operations described above, can produceundesirable results if the pertinent operands do not have sufficientgranularity. For example, if 10 is divided by 6, the result is 1,compared to the desired result of 5/3. To reduce these types ofproblems, the data may be appropriate scaled. Continuing with the aboveexample, if 10 is scaled up to 100 and then divided by 6, the result is5, which (when divided by 10), is closer to the desired number 5/3.Appropriate scaling is performed to compare quantities that have beenmaintained at different scales. Continuing with the above example, if athreshold (to be applied to the value 10/6) is 2, it is scaled to 20,which may then be compared with the scaled value of 5.

For ease of understanding, the scaling factors (which are device anddata dependent) have been omitted from the above description. Thepreferred scaling factors for various quantities are as follows. Withregard to blocks 262 and 314 of FIGS. 7 and 9 respectively, mStDevNavgand MStDevN_xavg are both scaled by a factor of 5. With regard to FIG. 6b, ST_int and ST_ind-Rpeak_ind are scaled by a factor of 16 for purposesof computing the exponential average in block 236. Because integer basedarithmetic results in rounding down of fractions, the quantity of ¼ isadded to compensate for bias that would otherwise result from suchtruncation. All QR related quantities are scaled by a factor of 128.

1. A cardiac monitor comprising: (a) a sensor adapted to sense an analogsignal from a heart; (b) a device coupled to the sensor, the devicehaving an analog-to-digital circuit system contained therein fordigitizing the analog signal to produce a digitized waveform; (c) aprocessor electrically coupled to the analog-to-digital circuit system,said processor configured to: (i) compute a plurality of ST deviationsfrom the digitized waveform, the plurality of ST deviations beingcharacterized by a statistical distribution characterized by an upperboundary and a lower boundary, the lower boundary being characterized bya boundary value; (ii) storing data pertaining to the plurality of STdeviations in a form that enables characteristics of the statisticaldistribution to be computed; (iii) form a lower detection threshold thatdepends on the difference between the boundary value and a preset value;(iv) compute a subsequent ST deviation from the digitized waveform; (v)apply a test to detect a cardiac event, wherein the test is based on thesubsequent ST deviation and the lower detection threshold.
 2. The systemof claim 1 wherein the lower detection threshold is equal to a firstfunction or a second function depending on whether the differencebetween the boundary value and the preset value exceeds a specifiedthreshold.
 3. The system of claim 2 wherein the second function is equalto the first function or a third function, whichever results in a lowerdetection threshold closer to the boundary value.
 4. The system of claim3 wherein the third function is equal to the sum of a preset value andthe boundary value.
 5. The system of claim 2 wherein the statisticaldistribution is characterized by a dispersion, and wherein the firstfunction is equal to a specified distance from the boundary value,wherein the specified distance is based on the dispersion.
 6. The systemof claim 1 wherein the preset value corresponds to a change in polarityof ST deviation.